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Anxiety Disorders. Dr Sheila Tighe. Lecture content. Psychology of normal anxiety Anxiety disorders - general features Specific disorders Panic disorder Generalised anxiety disorder Phobias OCD PTSD. Stress.

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Anxiety Disorders

Dr Sheila Tighe

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Lecture content

  • Psychology of normal anxiety

  • Anxiety disorders - general features

  • Specific disorders

    • Panic disorder

    • Generalised anxiety disorder

    • Phobias

    • OCD

    • PTSD

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  • Definition: Experiencing events that are perceived as endangering one’s physical or psychological well-being. The events are known as stressors and the result as the stress response

  • The response to stressors is influenced by

    • Controllability, predictability and challenge to our limits.

    • Holmes Life Events Scale

  • Different psychological responses to stress include

    • Anxiety

    • Anger and aggression

    • Apathy and depression

    • Cognitive impairment

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Definition of anxiety

  • A vague unpleasant emotion that is experienced in anticipation of some future misfortune

  • A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation

  • May have emotional, behavioural, cognitive and physical components

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Structures and neurotransmitters involved in anxiety

  • Structures involved

    • Cerebral cortex

    • Limbic system- hypothalamus, hippocampus, amygdala, cingulum

    • Thalamus, locus ceruleus, raphe nucleus

  • Neurotransmitters

    • NA, 5HT, GABA

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Fight or flight response

  • Physiological response to a stressor

  • Mediated through the hypothalamus and LC

  • Initial activation of the sympathetic nervous system

  • Subsequent activation of the pituitary adrenal axis

  • Terminated by negative feedback and para sympathetic system

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Effects of sympathetic stimulation

  • Mediated through noradrenaline and adrenaline

  • Increased heart rate and contractility

  • Increased respiratory rate

  • Sweating

  • Increased glucose availability

  • Shunting of blood to muscles

  • Increased muscle tension

  • Enhanced blood clotting

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Effects of HPA axis stimulation

  • Mediated through CRH, ACTH and cortisol

  • Promotes breakdown of glycogen to glucose in liver

  • Promotes glucose uptake into cells

  • CRH also activates locus ceruleus

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Anxiety as a normal adaptive function

  • Evolutionary viewpoint

    • Looks at traits in the context of natural selection and promotion of the species

    • Primitive environment with many physical dangers – anxiety had a protective function as a warning system and in helping escape

    • Anxiety - response to cues of potential danger

    • Protection general or specific depending on nature of threats c.f.. Immune system

    • Avoidance, aggression, freezing or appeasement

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Anxiety as a normal adaptive function continued

  • Preparedness - We are more likely to become anxious in response to cues that represent ancient dangers e.g.,snakes, strangers, storms, blood.

  • Not flowers, leaves, shallow water

  • Not in response to more evolutionary recent dangers - guns, cars

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Benefits of anxiety

  • Yerkes-Dodson law:

    • Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance

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Anxiety disorders - terminology

  • Neurosis – William Cullen

    • General deficiency of nervous system

  • Psychoneurosis – Sigmund Freud 1900

    • Unreleased sexual tension - hypochondriasis

    • Repressed thoughts - phobias

  • ICD10 – Neurotic, stress related and somatoform disorders.

  • DSM IV – Anxiety disorders

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Anxiety disorders

  • Anxiety disorders are extremes of normal anxiety

  • Occur when normal anxiety system becomes dysregulated - excessive, inappropriate or deficient

  • Common - ECA lifetime prevalence 15 -20%

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Shared features of anxiety disorders

  • Substantial proportion of aetiology is stress related.

  • Reality testing is intact.

  • Symptoms are ego dystonic (distressing)

  • Disorders are enduring or recurrent.

  • Demonstrable organic factors are absent

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Aetiology of anxiety disorders

  • Genetic

    • Family studies

    • Linkage studies

  • Neurotransmitter abnormalities

    • 5HT, NA, GABA

  • HPA axis dysregulation

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Aetiology of anxiety disorders

  • Psycho-analytic theories - unconscious defence mechanisms

    • Phobia - displacement

    • OCD - reaction formation, undoing

    • PTSD - denial, repression

  • Cognitive theories

    • Selective attention and catastrophic thinking

  • Behaviour - learned behaviour

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Anxiety disorders - aetiology

  • Social factors

    • Early life adversity

    • Stressful events especially those involving threat

    • Lack of support network

  • Personality factors

    • Some personality traits predispose to certain anxiety disorders – avoidant, perfectionist

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Panic Disorder

  • Recurrent attacks of severe anxiety

  • Physical symptoms

    • Palpitations, chest pain, choking sensation, dizziness, breathlessness, tingling in the hands and feet, sweating, faintness.

  • Emotional and behavioural symptoms

    • Fear of dying, losing control, going mad

    • Feeling of unreality - depersonalisation

    • Need to exit situation

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Panic Disorder continued

  • Sudden in onset

  • Not predictable or confined to a given situation

  • Concern about future attacks and secondary avoidance

  • Otherwise relatively free of anxiety between attacks

  • ICD10 criteria - several severe attacks within a month

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Panic disorder - differential

  • Panic attacks as part of a phobic disorder

    • distinction between panic disorder and agoraphobia controversial

  • Depression

  • PTSD

  • Substance abuse

  • Physical disorders e.g., phaeochromocytoma

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Panic disorder - epidemiology

  • ECA - 1% of population

  • More prevalent in females

  • Ages 25 - 44

  • 20% have another anxiety disorder

  • Positive family history of panic disorder in 25%

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Panic disorder - pharmacological treatment

  • Assess and tx comorbid problems

  • SSRIs - paroxetine, citalopram - can initially worsen panic attacks

  • Benzodiazepines - good short term relief but high risk of dependency - alprazolam

  • TCAs - imipramine, clomipramine

  • MAOIs - especially in mixed panic depressive states but use limited by ADR

  • High rate of relapse on cessation of tx

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Panic Disorder: The Cognitive Perspective

Tendency to interpret a range of bodily sensations in a catastropic fashion.

Selective attention to internal cues and avoidance compound the problem.

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Panic disorder - psychological treatments

  • Behavioural therapy

    • exposure and response prevention

    • relaxation techniques

  • Cognitive behaviour therapy

    • education

    • recognition and change of negative thoughts

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Generalised Anxiety Disorder

  • Anxiety is generalised and persistent

  • Free-floating anxiety – not situational.

  • ICD10 - symptoms present most days for weeks

  • Motor tension

    • Muscle tension, twitching and shaking, restlessness, .

  • Apprehension

    • Feeling on edge,unable to cope, poor concentration, insomnia, irritability

  • Autonomic over-activity

    • Lightheadedness, sweating, tachycardia, dry mouth, epigastric discomfort

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GAD - epidemiology

  • One year prevalence 3 - 8%

  • Females more likely 2:1

  • Age of onset 20 - 35

  • 50% have another psychiatric diagnosis

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GAD - differential

  • Other anxiety disorders

  • Depression

  • Substance abuse

  • Schizophrenia

  • Physical conditions

    • hyperthyroidism, angina

  • Early dementia

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GAD - Management

  • Biological

    • Benzodiazepines - short-term tx

    • SSRIs -

    • Venlafaxime

    • MAOIs

  • Psychological

    • Anxiety management - based on CBT principle

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  • Anxiety evoked by specific circumstances or situations. Fear is out of proportion to the situation and is beyond voluntary control.

  • Agoraphobia

  • Social phobia

  • Specific phobias

  • Plus or minus panic disorder

  • Avoidance is a characteristic feature

  • Strong association with depression

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  • Fear of open spaces, crowds or public places.

  • Fear of travelling by public transport

  • Fear that it may be difficult to get to a place of safety (home)

  • Situations where an immediately available exit is lacking are avoided.

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Agoraphobia - symptoms

  • Autonomic symptoms - faintness, palpitations, SOB, sweating

    • Panic attacks marker of severity

  • Psychological symptoms - fear, dread

  • Behavioural symptoms - avoidance to the extent that the person becomes house bound

  • Cognitive symptoms - “ I might have died”

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Agoraphobia - epidemiology(similar to panic disorder)

  • Predominantly females – 75%

  • Age of onset – 15 to 35

  • Risk factors

    • Stressful life events

    • Family history – 20% relative with agoraphobia

    • Domestic instability – family or marital difficulties

    • History of childhood fears or enuresis

    • Overprotective family members

  • Differential diagnosis

    • Depression, schizophrenia, dementia

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Agoraphobia - Management and Prognosis

  • Behaviour therapy - graded exposure and systematic desensitisation

  • CBT

  • Family therapy

  • Self help books

  • Pharmacotherapy - as for panic disorder

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Social Phobia

  • Fear of scrutiny by others in relatively small groups

  • Fear of acting in a way that will be embarrassing or humiliating or appear ridiculous

  • Feared social situation associated with intense anxiety and distress - blushing, tremor,butterflies

  • Leads to avoidance of social situations that involve e.g., eating, public speaking - isolation

  • Differential diagnosis

    • Body dysmorphic disorder, panic disorder, depression, paranoid psychosis

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Social phobia - epidemiology

  • Roughly equal sex incidence

  • Onset in adolescence

  • Prevalence - 1-2 %

  • Often co-morbid depression or alcohol and substance abuse

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Social phobia - management

  • Assess and treat co-morbid conditions

  • Pharmacotherapy

  • Behavioural and CBT techniques

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Specific phobias

  • Anxiety provoked only in response to a specific stimulus or situation

  • Panic attacks can occur

  • Degree of disability is related to ease or difficulty of avoiding the feared object

  • Feared object usually something that posed a threat at some time in history - animals, storms, heights, darkness, blood

  • Behavioural approach most useful

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Obsessive Compulsive Disorder

  • Repetitive unwanted obsessions or compulsive acts

  • Obsession is recurrent and intrusive thought, feeling, idea, image or impulses

    • Usually distressing e.g., contamination, obscene, violent

    • Sometimes futile e.g., quasi-philosophical

    • Indecision between two alternatives

    • Resisted but this causes tension

    • Recognised as the person’s own thoughts

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OCD continued

  • Compulsions are stereotyped behaviours repeated again and again

    • Cleaning, checking, tidying, counting,

    • Sometimes marked indecision or slowness

    • Not enjoyable or useful

    • May be thought of as protective in some way and can reduce anxiety

  • Autonomic symptoms present

  • Close links with depression

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OCD epidemiology

  • Lifetime prevalence 1 -2%

  • Equal sex incidence

  • Age of onset 20 - usually abrupt

  • Often delay of years in seeking tx

  • Course chronic and fluctuating

  • Often co-morbid anxiety disorders, (social phobia 25%), depression (67%), eating disorders

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OCD - Management

  • Behaviour therapy

    • Exposure and response prevention

    • Paradoxical injunctions

  • CBT - less useful

  • Pharmacotherapy

    • SSRIs, Clomipramine

    • Augmentation with quetiapine or risperidone

    • Clonazepam

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  • Psychosurgery - indicated rarely for severe intractable cases

  • Outcome 60% respond to SSRIs but relapse is common on cessation of tx

  • Predictors of poor outcome are male sex, early onset and obsessional slowness

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Disorders arising as a reaction to stress

  • Acute stress reaction

  • Post traumatic stress disorder

  • Adjustment disorders - mild transient response to stress precipitated by life events within the normal range

  • Clear-cut stressor or trauma without which disorder would not occur

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Acute stress reaction

  • Overwhelming traumatic experience involving threat to life, physical integrity or social position of individual or a loved one

  • RTA, battle, rape, multiple bereavement

  • Daze, disorientation, mixed picture

  • Withdrawn or agitated

  • Autonomic symptoms

  • Onset within minutes, resolves 48-72 hrs

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Post traumatic stress disorder PTSD

  • Delayed or protracted response to trauma ( often involving threat to life)

  • Onset usually within 6 months of event

  • Core symptom is “reliving the event”

    • Flashbacks, nightmares, waking dreams

  • Emotional numbness and detachment

  • Avoidance of activities, situations that remind person of trauma

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PTSD continued

  • Autonomic hyper arousal

  • Hypervigilance, increased startle, insomnia

  • Mood disorder - anxiety or depression

  • Abuse of alcohol or drugs

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  • SSRIs, Serotinergic TCAS

  • Behavioural tx

  • CBT

  • Family tx

  • Debriefing - no clear evidence base

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PTSD - outcome

  • Symptoms fluctuate over time

  • Most intense at times of stress

  • 30% complete recovery

  • 10 % do badly

  • Predictors of poor outcome - Hx of childhood trauma, borderline or ontisocial personality traits, poor support network, heavy alcohol intake

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Dissociative and somatoform disorders

  • Disorders in which person presents with physical symptoms for which there is no medical explanation

  • Psychological explanation or cause often present

  • Diagnosis of exclusion

  • Liaison psychiatry

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  • Anxiety disorders are common

  • They are distressing and cause loss of function

  • They occur commonly with other co-morbid psychiatric disorders

  • They are amenable to pharmacological and psychological treatment